Alcohol identification and brief advice

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Alcohol identification and brief advice

• Dr Graham Roberts

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Aim

• The aim of identification and administration of
  brief advice in relation to alcohol use is to
  identify those drinking at increasing and higher
  risk levels and implement brief advice in a
  structured way so as to reduce levels of alcohol
  consumption to lower risk. IBA does not aim to
  manage dependant drinkers.
• A key element is understanding alcohol units.

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Alcohol units

• To discuss alcohol consumption meaningfully, it
  is vital that both the giver and recipient of
  advice understand alcohol units
• 1 unit is equivalent to 10ml ( 8g ) of ethyl
  alcohol
• The formula for calculating units is
• ( volume in ml/1000 ) x abv
• Compared to 20 years ago, glass sizes tend to be
  bigger and alcoholic drinks contain a greater
  percentage of alcohol by volume

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Units in real terms

• Wine
• 125 ml of 8 wine 1 unit
• More typically however, a glass of wine will be
  175ml of 14 wine 2-3 units
• 1 bottle of wine 9 10 units

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• Beer, lager and cider
• ½ pint of 3.5 beer, lager or cider 1 unit
• 1 pint of 5 beer, lager or cider 3 units

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• Spirits
• 25ml of 40 spirits 1 unit
• Alcopops
• 1 alcopop 1.5 units

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Recommended limits

• Adult women should not regularly exceed 2 3
  units per day
• Adult men should not regularly exceed 3 4 units
  per day
• Higher risk drinking is defined as regularly
  drinking gt 6 units per day for women ( gt 35 units
  per week ) and gt 8 units per day for men ( gt 50
  units per week )

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Metabolism of alcohol

1. Alcohol levels peak in the blood approximately 1
   hour after consumption
2. Most alcohol is metabolised in the liver to
   acetaldehyde ( a process which uses thiamine ),
   at a rate of approximately 1 unit per hour.
3. A small proportion is excreted in breath, sweat
   and urine.

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Risk

• To clarify the terms used in relation to alcohol
  consumption and its risks, the DOH now
  recommends the terms
• Lower risk
• Increasing risk
• Higher risk

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Lower risk

• This term implies that no level of alcohol
  consumption is without risk

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Increasing risk

• This relates to
• Females regularly drinking gt 2 3 units per day
• Males regularly drinking gt 3 4 units per day

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Higher risk

• Higher risk refers to
• Women regularly drinking gt 6 units per day
• ( gt 35 units per week )
• Men regularly drinking gt 8 units per day
• ( gt 50 units per week )

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Binge drinking

• The term binge drinking is more a media term
  but refers to drinking gt 2 x the recommended
  daily maximum ( gt 6 units for a woman, gt 8 units
  for a man )

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Alcohol dependance

• Alcohol dependance affects around 3 of the
  population and is typified by
• Increasing drive to use alcohol
• Difficulty in controlling its use
• Often despite negative consequences that begin to
  build up
• Physical symptoms of withdrawal shaking hands,
  sweating, nausea, anxiety
• Identification and brief advice does not aim to
  target this group ( rather aims to target those
  at increasing and higher risk ) but we should be
  aware of how to identify them and signpost them
  to more appropriate sources of help.

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Data from the National Household Survey 2006
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Effects of drinking alcohol

• The effects of alcohol use can be classified into
• Physical
• Mental
• Social
• There are also legal implications of excessive
  drinking

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Alcohol identification and brief advice

• Benefits
• There is much evidence to show that early
  identification of problem drinking and delivery
  of brief advice can be very effective in reducing
  peoples drinking to lower risk levels.
• The evidence shows that 18 people who receive
  such advice will reduce their drinking to lower
  risk levels.
• This compares to 120 smokers who stop following
  brief advice ( 110 when NRT products are used ).

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IBA pathway

1. Initial screening test Audit-C
2. Full screening tool Audit
3. Implementation of brief advice
4. ( referral for specialist treatment if necessary )

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Tools to identify alcohol misuse

• Screening
• Audit-C ( Audit-consumption ) is derived from the
  first 3 questions of the full Audit
  questionnaire. It is quick to administer and will
  indicate if an individual is drinking at
  increasing or higher risk levels.
• A score of 5 indicates increasing or higher risk
  drinking.

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Audit-C
Questions Scoring system Scoring system Scoring system Scoring system Scoring system Your score
Questions 0 1 2 3 4 Your score
How often do you have a drink containing alcohol? Never Monthly or less 2 - 4 times per month 2 - 3 times per week 4 times per week
How many units of alcohol do you drink on a typical day when you are drinking? 1 -2 3 - 4 5 - 6 7 - 9 10
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? Never Less than monthly Monthly Weekly Daily or almost daily
Scoring A total of 5 indicates increasing or
higher risk drinking. An overall total score of 5
or above is AUDIT-C positive.
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• Assessment
• Full AUDIT questionnaire.
• As a screening tool it has a high sensitivity (
  92 ) and specificity ( 94 ).
• N.B. M-SASQ Sensitivity (91.8) Specificity
  (70.8)
• There are 10 questions and the results will
  accurately classify persons into low, increasing
  and high risk groups.
• Low risk score lt7
• Increasing risk score 8-15
• High risk score 16-19
• Possible dependance score 20-40

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Audit
Questions Scoring system Scoring system Scoring system Scoring system Scoring system Your score
Questions 0 1 2 3 4 Your score
How often do you have a drink containing alcohol? Never Monthly or less 2 - 4 times per month 2 - 3 times per week 4 times per week
How many units of alcohol do you drink on a typical day when you are drinking? 1 -2 3 - 4 5 - 6 7 - 9 10
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? Never Less than monthly Monthly Weekly Daily or almost daily
How often during the last year have you found that you were not able to stop drinking once you had started? Never Less than monthly Monthly Weekly Daily or almost daily
How often during the last year have you failed to do what was normally expected from you because of your drinking? Never Less than monthly Monthly Weekly Daily or almost daily
How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? Never Less than monthly Monthly Weekly Daily or almost daily
How often during the last year have you had a feeling of guilt or remorse after drinking? Never Less than monthly Monthly Weekly Daily or almost daily
How often during the last year have you been unable to remember what happened the night before because you had been drinking? Never Less than monthly Monthly Weekly Daily or almost daily
Have you or somebody else been injured as a result of your drinking? No Yes, but not in the last year Yes, during the last year
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? No Yes, but not in the last year Yes, during the last year
Scoring 0 7 Lower risk, 8 15 Increasing
risk, 16 19 Higher risk, 20 Possible
dependence
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Brief intervention - FRAMES

• ( Sanchez and Miller, 1993 )
• Brief intervention has six essential elements
• FEEDBACK provide feedback on the patients risk
  for alcohol problems
• RESPONSIBILITY highlight that the individual is
  responsible for change
• ADVICE advise reduction or give explicit
  direction to change
• MENU provide a variety of options for change
• EMPATHY emphasise a warm, reflective and
  understanding approach
• SELF-EFFICACY encourage optimism about changing
  behaviour

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Feedback for lower risk drinkers

• Provide feedback about results of the test
• Educate that exceeding recommended levels of
  alcohol intake is associated with alcohol-related
  health problems like accidents, injuries, high
  blood pressure, liver disease, cancer and heart
  disease
• Congratulate patients for their adherence to the
  guidelines

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Structured feedback tools

• Clinical trials from early intervention
  programmes indicate that brief advice, using a
  patient education leaflet ( structured advice
  tool ), is effective and consequently the
  intervention tool of choice.
• Feedback and advice should be structured
  according to the patients readiness to change.

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The stages of change
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Structured advice tool
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Single Sided Advice.
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Feedback

1. Give feedback on the common effects of drinking
2. Give feedback on other peoples drinking habits
3. Give feedback on the benefits of reduction
4. Give a menu of options to encourage a goal
5. Give advice on units and limits

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Empathy responsibility

• Be empathic and non-judgemental patients are
  often unaware of the risks of drinking
  excessively and drinking at increasing or higher
  risk levels is often not a permanent condition
  but a pattern into which people fall for a period
  of time. Condemnation may jeopardise the
  relationship resulting in advice being rejected
  and defeating the object of the intervention

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Be authoritative, advise reduction

• Be clear and objective, dont undermine the
  recommended limits by admitting that you exceed
  them or regard them as arbitrary.

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Deflect denial

• Some patients may not be ready for change.
• They may deny that they drink too much and become
  defensive at the suggestion that they cut down.
• Do not get drawn into confrontation, aim to
  motivate them by giving factual information and
  expressing genuine concern.

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Highlight that the individual is responsible for
change

• It is vital that the patient is in charge of goal
  setting and provides some suggestions as to how
  they can cut down.
• Engage them in a conversation about what is best
  for them, it is inappropriate to dictate to them
  and tell them what to do.

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Follow up

• After administering brief advice it is important
  to create a plan for follow up

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Dependant drinking

• IBA is not designed for persons drinking at
  dependant levels. The following characteristics
  should prompt referral to more specialist alcohol
  services
• Alcohol related harm
• Accidents, trips, falls
• Increasing or higher risk drinkers wanting more
  help
• Audit score of 20
• Severe alcohol related problems such as loss of
  job or family
• Symptoms of dependance

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Wernicke Korsakoff syndrome

• Caused by thiamine ( vitamin B1 ) deficiency
• Wernickes encephalopathy is the acute or
  subacute mainfestation of the syndrome and
  Korsakoffs psychosis is the chronic form
• In alcohol dependant individuals, Wernickes
  encephalopathy may be precipitated by alcohol
  withdrawal or by intercurrent illness.
• The encephalopathy has an abrupt onset with a
  classic triad of mental confusion, ataxia and
  ocular abnormalities.
• However the symptoms or signs may only be present
  in part and it is important to have a high index
  of suspicion.
• The acute stage has a 17 20 death rate and is
  hence a medical emergency treated with high dose
  parenteral thiamine.

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• Korsakoffs syndrome may emerge as a chronic
  disorder following an episode of Wernickes
  encephalopathy or insidiously with no clear prior
  history.
• The main deficit is in recent memory. New
  learning is also impaired. They often have little
  insight.
• It is likely to be underdiagnosed in clinical
  practice with overlap with alcoholic dementia.
• It is irreversible

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Prevention

• Dependant drinkers should be treated with
  thiamine and vit B Co-strong supplements as a
  preventative measure.